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Outcome of early cholecystectomy compared to percutaneous drainage of gallbladder and delayed cholecystectomy for patients with acute cholecystitis: systematic review and meta-analysis

Open AccessPublished:May 05, 2022DOI:https://doi.org/10.1016/j.hpb.2022.04.010

      Abstract

      Background

      Compare outcomes of early laparoscopic cholecystectomy (ELC) and percutaneous trans-hepatic drainage of gallbladder (PTGBD) as an initial intervention for AC and to compare operative outcomes of ELC and delayed laparoscopic cholecystectomy (DLC).

      Methods

      English-language studies published until December 2020 were searched. Randomised controlled trials (RCTs) and observational studies compared EC and PTGBD with delayed cholecystectomy for patients presented with acute cholecystitis were considered. Main outcomes were mortality, conversion to open, complications and length of hospital stay.

      Results

      Out of 1347 records, 14 studies were included. 205,361 (94.7%) patients had EC and 11,565 (5.3%) patients had PTGBD as an initial intervention for AC. Mortality was higher in PTGBD; HR, 95% CI: [3.68 (2.13, 6.38)]. In contrast, complication rate was significantly higher in EC group (47%) vs PTGBD group (8.7%) in patients admitted to ICU; P-value = 0.011. Patients who had ELC were at higher risk of post-operative complications compared to DLC; RR [95% CI]: 2.88 [1.78, 4.65]. Risk of bile duct injury was six folds more in ELC; RR [95% CI]: 6.07 [1.67, 21.99].

      Conclusion

      ELC may be a preferred treatment option over PTGBD in AC. However, patient and disease specific factors should be considered to avoid unfavourable outcomes with ELC.

      Introduction

      Acute cholecystitis (AC) is the most common complication of gallstone disease with about 12% of gallstone patients can develop AC in their lifetime.
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      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      Cholecystectomy is the definitive treatment for symptomatic gallstone disease aiming to eliminate or reduce biliary pain and it also reduces risk of complications such as recurrence of AC, common bile duct stones or gallstone pancreatitis.
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      The treatment of gallstone disease.
      Moreover, early cholecystectomy for AC is associated with less gallstone disease related hospital admissions and less total treatment cost even in elderly patients.
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      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      For uncomplicated AC in low risk surgical patient, early laparoscopic cholecystectomy (ELC) is the recommended treatment option.
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      Management can be difficult in complicated AC or in high risk surgical patients not responding to conservative treatment and percutaneous transhepatic gallbladder drainage (PTGBD) is an option to avoid possible high risk surgery.
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      However, PTGBD is not a definitive treatment and is associated with more unfavourable long-term outcomes such as total hospital stay and recurrent admissions.
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      • Loozen C.S.
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      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      • Hall B.R.
      • Armijo P.R.
      • Krause C.
      • Burnett T.
      • Oleynikov D.
      Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis.
      There is an agreement between Tokyo guidelines (TG) 2018, National Institute for Health and Care Excellence (NICE), Association of Upper Gastrointestinal surgery of Great Britain and Ireland (AUGIS) and World Society of Emergency Surgery (WSES) 2020 guidelines that ELC should be offered to AC patients as first option whenever the risk of surgical intervention deemed acceptable.
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      • Cimbanassi S.
      • Boerna D.
      • et al.
      2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis.
      ,
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      • Asbun H.J.
      • Endo I.
      • et al.
      Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis.
      ,
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      Diagnosis and management of gallstone disease: summary of NICE guidance.
      ,

      AUGIS (2015). Pathway for the management of acute gallstone diseases. Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. http://www.augis.org.

      In TG 2018 and WSES guidelines, PTGBD is an alternative option if the surgical treatment is considered high risk and expected to be associated with more unfavourable outcomes compared with PTGBD. However, there is discrepancy in criteria to select ELC or PTGBD and most of recommendations were based on low-quality evidence.
      • Jeon H.W.
      • Jung K.U.
      • Lee M.Y.
      • Hong H.P.
      • Shin J.H.
      • Lee S.R.
      Surgical outcomes of percutaneous transhepatic gallbladder drainage in acute cholecystitis grade II patients according to time of surgery.
      The aim of this review is to compare outcomes of ELC and PTGBD as an initial intervention for AC and to compare operative outcomes of ELC and post PTGBD delayed laparoscopic cholecystectomy (DLC). Predictors of selecting PTGBD over ELC in practise are also studied. This allows comparing early cholecystectomy vs PTGBD followed by DLC as two management pathways for patients admitted with AC.

      Methods

      This review was prepared in line with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement. This systematic review was registered to PROSPERO (registration number: CRD42021262443).
      English-language studies published between 1946 and December 2020 were searched.
      Randomised controlled trials (RCTs) and observational studies compared early cholecystectomy (EC) and percutaneous trans-hepatic drainage of gallbladder (PTGBD) with delayed cholecystectomy for patients presented with acute cholecystitis were initially considered. Systematic reviews were excluded but considered in discussion. Only studies with target population of patients acutely presented with acute cholecystitis (AC) were included. Patients who presented with AC and did not require any intervention at index admission, whether PTGBD or EC were excluded. Main outcomes were mortality, conversion to open, complications and length of hospital stay.
      Electronic database search was conducted in Ovid Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Review (CDSR). The search was conducted by a senior information specialist from the library department of the Royal College of Surgeons of England and was executed on the 17th of December 2020. Patient Intervention Control Outcome (PICO) framework was used to guide the search (Supplementary Table 1). Full electronic search strategy is shown in Supplementary Tables 2a–c.
      Two independent blinded reviewers performed the abstract screening. Any conflicts were resolved by a third reviewer to produce the final list of studies eligible for full-text review. Full text review carried out by one reviewer and results were checked by a senior researcher.
      Data from individual studies were extracted by two independent blinded researchers on Excel spread sheet and checked by another independent researcher to confirm adequacy and accuracy of data extracted. Data included individual study details, demographic data, type of treatment, disease characteristics and outcomes in both treatment arms. Follow up period from each study were also noted. Observational studies were classified according to Mathes and Pieper criteria.
      • Mathes T.
      • Pieper D.
      Clarifying the distinction between case series and cohort studies in systematic reviews of comparative studies: potential impact on body of evidence and workload.
      The revised Cochrane risk-of-bias tool for RCTs (RoB2 Tool) was used to assess risk of bias in RCTs and Joanna Briggs Institute (JBI) assessment tool used to assess observational studies.
      ,
      For JBI appraisal tool, overall risk of bias of specific study was decided based on how many questions were answered with yes, no or unclear. The study will be of low concern of bias if there is unfavourable answer to one question or less, some concern if 2 to 3 questions and high concern if 4 or more questions.

      Statistical analysis

      Count, percentages, and ratios were used to represent non-continuous variables and median (range) was used to represent continuous data as stated in each individual study. Range of mean values was used to represent continuous variable across studies that could not be combined. Meta-analysis of categorical variables such as post-operative complications, were represented by risk ratios (RR) (hazard ratio (HR) for mortality) and 95% confidence interval (CI). Continuous variables such as age were represented by mean difference (MD) and 95% CI.
      Meta-analysis was conducted using RevMan (Review Manager) software version 5.4 if allows. I2 and Tau2 tests were performed to assess heterogeneity. If I2 > 50%, significant heterogeneity will be considered and Mantel–Haenszel (M−H) random effect model to be employed.
      • Barili F.
      • Parolari A.
      • Kappetein P.A.
      • Freemantle N.
      Statistical primer: heterogeneity, random- or fixed-effects model analyses?.
      Chi-square test was used to compare the studies reporting number of high-risk surgical patients and/or patients with complicated AC who had PTGBD compared to the rest of studies. A P-value of less than 0.05 was taken as statistically significant.

      Handling of confounding factors

      Patients and disease characteristics were highlighted and compared in EC vs PTGBD and ELC vs DLC comparisons.

      Operational definitions

      EC: early cholecystectomy performed at the index admission for AC.
      ELC: early laparoscopic cholecystectomy.
      PTGBD: Percutaneous transhepatic gallbladder drainage.
      DLC: Delayed laparoscopic cholecystectomy performed after PTGBD.
      Post PTGBD-DLC: DLC after PTGBD.
      Complicated acute cholecystitis: Tokyo classification of Grade II or more AC
      • Yokoe M.
      • Hata J.
      • Takada T.
      • Strasberg S.M.
      • Asbun H.J.
      • Wakabayashi G.
      • et al.
      Tokyo guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).
      or Presence of systemic sepsis, empyema, gangrene, perforation, abscess, or gallbladder (GB) wall thickness ≥ 4 mm.
      Grade II acute cholecystitis: AC that fulfils any one of the following criteria: elevated white blood cell count (>18,000/mm3), palpable tender mass in the right upper abdominal quadrant, duration of complaints >72 h, or marked local inflammation (pericholecystic abscess, gangrenous cholecystitis, hepatic abscess, biliary peritonitis, emphysematous cholecystitis).
      • Yokoe M.
      • Hata J.
      • Takada T.
      • Strasberg S.M.
      • Asbun H.J.
      • Wakabayashi G.
      • et al.
      Tokyo guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).
      Major complications: Clavien–Dindo classification (CD)
      • Clavien P.A.
      • Barkun J.
      • de Oliveira M.L.
      • Vauthey J.N.
      • Dindo D.
      • Schulick R.D.
      • et al.
      The Clavien-Dindo classification of surgical complications: five-year experience.
      of 3 or more or presence of intra-abdominal abscess, pneumonia, myocardial infarction or pulmonary embolism within 30 days after randomisation or recurrent biliary disease or need for reintervention within one year.
      BDI: Bile duct injury. This term also included bile leak or biloma.

      Patient's morbidity and risk evaluation systems

      • -
        APACHE II: Acute physiology assessment and chronic health evaluation II.
        • Hansted A.K.
        • Møller M.H.
        • Møller A.M.
        • Vester-Andersen M.
        Apache II score validation in emergency abdominal surgery. A post hoc analysis of the InCare trial.
      • -
        ASA: The American Society of Anaesthesiologists classification.
        • Irlbeck T.
        • Zwißler B.
        • Bauer A.
        ASA classification : transition in the course of time and depiction in the literature.
      • -
        SOI: Severity of illness scoring system.
        • Keegan M.T.
        • Gajic O.
        • Afessa B.
        Severity of illness scoring systems in the intensive care unit.
      High risk surgical patient is defined as a patient who meets any of these criteria: APACHE II score of 7 or more, SOI score of 3 or more, ASA score of 3 or more or admission to intensive care unit (ICU).

      Results

      Study selection process is demonstrated on the PRISMA diagram (Fig. 1). 1347 records were identified on the initial search after excluding 646 duplicates. 21 studies were eligible for full text review. Of which, 7 studies were excluded for either not fulfilling the study question criteria or no comparison performed to produce a final list of 14 studies. 2 studies were randomised controlled trials and 12 were observational studies. Risk of bias assessment for RCTs has shown some concern for one study
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      and high concern for the other study
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      (Supplementary Table 3). Six observational studies were identified to have high concerns of bias (Supplementary Tables 4a, b and Table 1).
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Schlottmann F.
      • Gaber C.
      • Strassle P.D.
      • Patti M.G.
      • Charles A.G.
      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      ,
      • Hall B.R.
      • Armijo P.R.
      • Krause C.
      • Burnett T.
      • Oleynikov D.
      Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      Table 1Study details
      Study and yearRisk of biasDesignInclusion/exclusion criteriaEarly cholecystectomyTiming/definition of ECDLC + PTGBDTiming of LC after PTGBDOutcome domains
      Choi et al. 2012
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      High concernsRetrospective cohortIncluded only patients with diagnosis of complicated AC based on clinical, imaging and peri-operative findings. Excluded patients with cholangitis based on ERCP or MRCP63LC within 72 h from admission40Average 7.9 days – minimum 5 daysOperative time, development of complications, LOS
      El-Gendi et al. 2017
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      High concernsRandomised controlled trialPatients with grade II acute cholecystitis and presented >72 h after onset of symptoms.

      Excluded patients admitted to ICU, pregnancy and a calcular cholecystitis
      75Within 24 h756 weeksConversion to open, complications, mortality, post-operative LOS
      Endo et al. 2017
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      Low concernsInternational multicentre

      Retrospective cohort
      Diagnosis of AC in patients aged 18 years or more2947

      1921 (67.4%) had primary laparoscopic approach
      Within median interval of 3 days (70% had cholecystectomy by day 3)1239 had cholecystectomy following PTGBD

      531 had PTGBD alone
      Median interval of 22 days (range: 1–802 days)

      Mean ± SD 39.9 ± 76.4 days
      Post-operative bile leak, major BDI, conversion to open, overall morbidity, operative time, LOS and post-operative complications
      Hall et al. 2018
      • Hall B.R.
      • Armijo P.R.
      • Krause C.
      • Burnett T.
      • Oleynikov D.
      Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis.
      High concernsMulticentre, retrospective cohortIncluded high risk surgical patients based of SOI scoring system. Included only patients scored 3 or 47879

      7221 (91.6%) had primary laparoscopic approach
      Not specified1682 (PTGBD only)Not specifiedLOS, cost, mortality, complications
      Huang et al. 2007
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      High concernsRetrospective cohortIncluded patients with GB perforation secondary to AC. Excluded patients younger than 14 years old and patients with traumatic GB perforation16 (OC)Not specified17 (PTGBD) – 6 had elective OCNot specifiedMortality, LOS, complications
      Jia et al. 2018
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      Some concernsRetrospective cohortIncluded patients with clinical and radiological evidence of AC associated with severe systemic disease and ASA score of 3 or more. Excluded patients with CBD stones or cholangitis.48Within 1 day383–5 daysOperative time and complications, conversion to open, post-operative complications, LOS, mortality
      Karakayali et al. 2014
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      Low concernsProspective cohortOnly included low risk surgical patients with ASA score of 1 or 2 presented with symptoms for 72 h or more and not responded to medical treatment for at least 48 h due to AC48Not specified434–8 weeksConversion to open, intraoperative bleeding, post-operative complications, LOS
      Kim et al. 2011
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      Some concernsRetrospective cohortIncluded patients with AC who had initial medical treatment for 12–24 h. Excluded asymptomatic patients, known chronic cholecystitis, gallbladder polyps or malignancy on permanent treatment147mean time interval 42.2 h from admission97 had PTGBD – 94 (97%) had DLC(DLC <7 days after PTGBD)

      Mean time interval 188.4 h
      Operative time, conversion to open, complications, mortality, LOS
      La Greca et al. 2017
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      High concernsRetrospective cohortIncluded patients admitted with AC based on clinical and radiological criteria556During index admission90 (13 of them had subsequent LC)Not specifiedMortality, LOS, Clavien–Dindo classification of post-operative morbidity
      Lee et al. 2017
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      Some concernsRetrospective cohortIncluded patients underwent LC for moderate to severe AC according to TG13. Excluded patients with a history of upper abdominal surgery or ERCP for CBD stones.4136 had LC within 24 h/3 had LC 1-3d/2 had LC > 7d44mean 30 days after PTGBDOperative time, conversion to open, post-operative complications. Evaluated predictors of prolonged operative time in PTGBD + LC group
      Loozen et al. 2018 (CHOCOLATE trial)
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      Some concernsMulticentre Randomised controlled TrialIncluded adults with calculous cholecystitis and a high surgical risk defined by APACHE II of 7 or more

      Excluded patients with APACHE II score of 15 or more
      66 (2 patients did not have LC: one needed ERCP and one had hyponatremia)Within 24 h of randomisation time interval from the onset of symptoms: median (IQR): 3 (2–3) days68 randomised to PTGBD. PTGBD was left for 3 weeks then checked by cholangiogram. Further treatment was left to the discretion of treating clinician3 weeksPrimary end points: death within one year and major complications. (Major complications defined as presence of intra-abdominal abscess, pneumonia, myocardial infarction or pulmonary embolism within 30 days after randomisation or recurrent biliary disease or need for reintervention within one year).

      Secondary end points: individual components of primary outcome, minor complications and difficulty of cholecystectomy (as scored by a visual analogue from 1 to 10)
      Melloul et al. 2011
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      High concernsRetrospective cohortPatients with sepsis related to acute calculous/acalculous cholecystitis admitted to ICU. Excluded patients with additional cholangitis or pancreatitis19

      Only 10 (52.6%) had primary laparoscopic approach.
      Not specified23 (PTGBD)Not specified90 days mortality, overall, minor and major complication rates, LOS in hospital and in ICU
      Ni et al. 2015
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      Some concernsRetrospective case-controlPatients diagnosed with acute cholecystitis and underwent LC or PTGBD. Excluded patients had open surgery, history of previous upper abdominal surgery, CBD stones, complications of other acute abdominal condition33Not specified26 (64 patients did not have PTGBD-36 – had PTGBD alone)Within 1 yearRemission of symptoms, operative time, intra-operative blood loss, conversion to open, LOS
      Schlottmann et al. 2018
      • Schlottmann F.
      • Gaber C.
      • Strassle P.D.
      • Patti M.G.
      • Charles A.G.
      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      High concernsRetrospective national cohortIncluded 65 years or older patients admitted with a primary diagnosis of acute cholecystitis who underwent either cholecystectomy of PTGBD during index hospitalisation193,399Not specified7516 had PTGBDNot specifiedPost-procedural complications, mortality, LOS and total cost
      ERCP, endoscopic retrograde cholangiopancreatography; MRCP, magnetic resonance cholangiopancreatography; LC, laparoscopic cholecystectomy; LOS, length of hospital stay; ICU, intensive care unit; GB, gallbladder; OC, open cholecystectomy; TG13, Tokyo Guidelines 2013; CBD, common bile duct.
      Out from 14 studies, 205,361 (94.7%) patients had early cholecystectomy and 11,565 (5.3%) patients had PTGBD as an initial intervention for acute cholecystitis. In 13 studies, laparoscopic intervention was the initial approach in 10,253 (85.7%) patients undergoing early cholecystectomy.
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • Hall B.R.
      • Armijo P.R.
      • Krause C.
      • Burnett T.
      • Oleynikov D.
      Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis.
      ,
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      From 2276 patients had PTGBD, 1618 (71.1%) patients had subsequent cholecystectomy as reported from 10 studies.
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.

      Timing of early cholecystectomy (EC)

      Timing of early cholecystectomy was not specified in seven studies.
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Schlottmann F.
      • Gaber C.
      • Strassle P.D.
      • Patti M.G.
      • Charles A.G.
      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      ,
      • Hall B.R.
      • Armijo P.R.
      • Krause C.
      • Burnett T.
      • Oleynikov D.
      Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis.
      ,
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      ,
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      ,
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      On the remaining seven studies, there was a high variation, and range of time interval from hospital admission to surgery was from 24 h to 7 days.
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      Two studies specified at least 72 h from the onset of symptoms as an inclusion criteria.
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      Mean duration of symptoms before intervention ranged from 2.25 to 7.4 days in four studies.
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      ,
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      ,
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      (Table 1).

      Time interval between PTGBD and delayed cholecystectomy

      A considerable variability was present across studies. From nine studies, time interval ranged from 3 to 802 days.
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      (Table 1).

      Patients and disease characteristics and predictors of PTGBD

      Mean age ranged from 49.65 to 80 years in 13 studies.
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Schlottmann F.
      • Gaber C.
      • Strassle P.D.
      • Patti M.G.
      • Charles A.G.
      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      ,
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      There was no significant age difference between PTGBD and EC groups; MD, 95% CI: [0.97 (−2.29, 4.22)]. 101,741 (47.3%) patients were males and male gender was not a risk factor for PTGBD; RR, 95% CI: [0.97 (0.87, 1.07)].
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Schlottmann F.
      • Gaber C.
      • Strassle P.D.
      • Patti M.G.
      • Charles A.G.
      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      ,
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • Hall B.R.
      • Armijo P.R.
      • Krause C.
      • Burnett T.
      • Oleynikov D.
      Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis.
      ,
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      Body mass index (BMI) was statistically higher in patients had EC in four studies; MD, 95% CI: [−0.43 (−0.67, −0.19)].
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      Mean ASA score ranged from 1.24 to 4.06 in eight studies and tended to be higher in PTGBD group; MD,95% CI: [0.29 (0.00, 0.59)].
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      (Supplementary Fig. 1).
      Four studies included only high risk surgical patients according to different scoring systems (Table 1).
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • Hall B.R.
      • Armijo P.R.
      • Krause C.
      • Burnett T.
      • Oleynikov D.
      Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      In those four studies, incidence of PTGBD (21.6%) was significantly higher than the rest of studies (4.7%); P-value <0.00001. Six studies included only patients with complicated acute cholecystitis
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      and the PTGBD incidence (46.9%) was significantly higher than the rest of studies (5.2%); P-value <0.00001. Two studies included 128 high risk surgical patients admitted with complicated AC
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      and PTGBD was significantly more commonly performed (47.7%) compared to studies included only high risk surgical patients with uncomplicated AC (21.2%); P-value <0.00001.
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • Hall B.R.
      • Armijo P.R.
      • Krause C.
      • Burnett T.
      • Oleynikov D.
      Emergent cholecystectomy is superior to percutaneous cholecystostomy tube placement in critically ill patients with emergent calculous cholecystitis.
      However, there was no statistical significance between high-risk surgical patients with complicated AC and patients with only complicated AC; P-value = 0.88 (Supplementary Table 5).
      Patients with diabetes mellitus [RR, 95% CI (1.6 (1.3,1.98))],
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Schlottmann F.
      • Gaber C.
      • Strassle P.D.
      • Patti M.G.
      • Charles A.G.
      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      ,
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      cardiovascular disease [RR, 95% CI (1.78 (1.75,1.81))],
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Schlottmann F.
      • Gaber C.
      • Strassle P.D.
      • Patti M.G.
      • Charles A.G.
      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      ,
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      respiratory disease [RR, 95% CI (1.57 (1.08, 2.28))],
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Schlottmann F.
      • Gaber C.
      • Strassle P.D.
      • Patti M.G.
      • Charles A.G.
      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      ,
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      cerebrovascular disease [RR, 95% CI (1.72 (1.27, 2.33))],
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      chronic kidney disease [RR, 95% CI (2.21, (1.33,3.67))],
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Schlottmann F.
      • Gaber C.
      • Strassle P.D.
      • Patti M.G.
      • Charles A.G.
      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      ,
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      and liver disease [RR, 95% CI (1.63 (1.25, 2.13))]
      • La Greca A.
      • Di Grezia M.
      • Magalini S.
      • Di Giorgio A.
      • Lodoli C.
      • Di Flumeri G.
      • et al.
      Comparison of cholecystectomy and percutaneous cholecystostomy in acute cholecystitis: results of a retrospective study.
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      were at higher risk to have PTGBD rather than EC (Supplementary Fig. 2a, b).
      Body temperature at admission was higher in PTGBD group but this was not statistically significant; MD, 95% CI [0.37 (−0.06, 0.81)].
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      There was no difference between PTGBD and EC groups regarding duration of symptoms prior to intervention; MD, 95% CI [−0.04 (−0.19, 0.11)]
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      ,
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      ,
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      (Supplementary Fig. 3).
      C-reactive protein (CRP) was significantly higher in patients underwent PTGBD; MD, 95% CI [3.37 (2.71, 4.03)].
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      ,
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      However, there was no difference in white blood count (WBC) between both groups; MD, 95% CI [0.74 (−0.32, 1.8)]
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      (Supplementary Fig. 4).
      Liver functions tests (LFTs) did not show significant difference between both groups for aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and bilirubin with MD, 95% CI: 7.44 (−9.40, 24.27), 3.62 (−10.14, 17.38), 28.35 (4.05, 52.65) and 0.30 (−0.08, 0.67), respectively from two studies
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      (Supplementary Fig. 5).
      Albumin level was lower in PTGBD group but this was not significant; MD, 95% CI: −2.81 (−6.88, 1.26).
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      APACHE II scoring system did not show considerable difference in three studies; MD, 95% CI: 0.53 (−0.62, 1.68)
      • Loozen C.S.
      • van Santvoort H.C.
      • van Duijvendijk P.
      • Besselink M.G.
      • Gouma D.J.
      • Nieuwenhuijzen G.A.
      • et al.
      Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial.
      ,
      • Huang C.C.
      • Lo H.C.
      • Tzeng Y.M.
      • Huang H.H.
      • Chen J.D.
      • Kao W.F.
      • et al.
      Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      (Supplementary Fig. 6).

      Outcomes of PTGBD vs EC

      Patients who had PTGBD were at more than three times risk of mortality compared to EC group; HR, 95% CI: [3.68 (2.13, 6.38)] (Supplementary Fig. 7).
      • Melloul E.
      • Denys A.
      • Demartines N.
      • Calmes J.M.
      • Schafer M.
      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.
      ,
      • Schlottmann F.
      • Gaber C.
      • Strassle P.D.
      • Patti M.G.
      • Charles A.G.
      Cholecystectomy Vs. cholecystostomy for the management of acute cholecystitis in elderly patients.
      ,
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      ,
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      For patients aged 65 years or older, overall post-procedural complications were significantly higher in patients who had PTGBD (30.6%) compared to patients who had EC (15.2%); P-value <0.0001.
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      Likewise, in high risk surgical patients, PTGBD group had about three folds complications rate (13.3%) compared to EC group patients who had laparoscopic approach (4.9%); P-value<0.05.
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      In contrast, complication rate was significantly higher in EC group (47%) vs 8.7% in PTGBD group in patients admitted to intensive care unit (ICU) for sepsis related to AC; P-value = 0.011.
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      Moreover, ELC had about 10 folds less risk of having recurrent biliary disease and 10 folds less risk of need for surgical intervention within one year of randomisation; RR (95% CI): 0.09 (0.03–0.27) and 0.10 (0.03–0.30), P-values: <0.001, respectively.
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      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
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      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
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      days, respectively; P value = 0.17.
      • Melloul E.
      • Denys A.
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      Percutaneous drainage versus emergency cholecystectomy for the treatment of acute cholecystitis in critically ill patients: does it matter?.

      Outcomes of ELC vs post PTGBD-DLC

      • -
        Characteristics of both groups:
      Eight studies compared outcomes of ELC and post PTGBD-DLC.
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      Laparoscopic approach was the main primary approach in the majority of patients (Table 1). 3458 (67.7%) patients had ELC, and 1653 (32.3%) patients had post PTGBD-DLC. Patients were nearly 4 years younger in ELC group; MD (95% CI): −3.72 [−7.14, −0.30].
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      Less males were in the ELC compared to post PTGBD-DLC groups; RR (95% CI); 0.95 [0.90, 0.99].
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
      • Takada T.
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      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      • Jia B.
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      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
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      • Jung J.P.
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      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
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      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      serum CRP tended to be lower in the ELC; MD (95% CI): −3.37 [−4.03, −2.72].
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
      • Takada T.
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      • Akazawa K.
      • Mori R.
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      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      ,
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      Body mass index (BMI) was higher in the ELC group; MD (95% CI): 0.45 [0.20, 0.69].
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
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      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      Patients with DM, hypertension, cardiovascular disease, cerebrovascular disease or liver disease are less likely to have ELC; RR (95% CI): 0.69 [0.61, 0.77],
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
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      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
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      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      0.83 [0.73, 0.94],
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      0.51 [0.41, 0.65],
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
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      ,
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      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
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      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      0.58 [0.43, 0.79]
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      and 0.65 [0.49, 0.87],
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      respectively. Duration of symptoms was longer in ELC group, but this was not significant; MD (95% CI): 0.37 [−0.07, 0.81] days.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      ,
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • -
        Intra-operative outcomes:
      Operative time was about 13 min longer in ELC but this was not significant; MD (95% CI): 13.21 (−3.11, 29.54) min.
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      ELC group had significantly more intra-operative blood loss than post PTGBD-DLC group; MD (95% CI): 34.2 (4.15, 64.25) ml.
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      Patients underwent ELC were at about two times risk of open conversion of laparoscopic cholecystectomy compared to post PTGBD-DLC group but this was not statistically significant; RR (95% CI): 2.16 [0.93, 5.00] (Fig. 2).
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      No patient had subtotal cholecystectomy in post PTGBD-DLC group compared to 13 (17.3%) patients in the ELC group; P value <0.001.
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      • -
        Post-operative outcomes:
      Figure 2
      Figure 2Intra-operative outcomes (ELC vs post PTGBD-DLC); a) operative time, b) blood loss(ml), c) risk of conversion to open
      There was no difference in mortality between the two groups; HR (95% CI): 1.30 [0.60, 2.83].
      • Endo I.
      • Takada T.
      • Hwang T.L.
      • Akazawa K.
      • Mori R.
      • Miura F.
      • et al.
      Optimal treatment strategy for acute cholecystitis based on predictive factors: Japan-Taiwan multicenter cohort study.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      Patients had ELC are at about three times risk of post-operative complications compared to those had post PTGBD-DLC; RR [95% CI]: 2.88 [1.78, 4.65].
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      Risk of bile leak or bile duct injury (BDI) was six folds more in ELC; RR [95% CI]: 6.07 [1.67, 21.99].
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      Similarly, ELC group were at higher risk of developing sub-hepatic collection but this was not significant; RR [95% CI]: 2.62 [0.83, 8.34].
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      Likewise, risk of wound site complications was higher in ELC but not statistically significant; RR [95% CI]: 1.73 [0.65, 4.58].
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      ,
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      (Fig. 3).
      Figure 3
      Figure 3Post-operative outcomes (ELC vs post PTGBD-DLC); a) mortality, b) post-operative complications, c) bile duct injury, d) sub-hepatic collection, e) wound site complications
      Patients from ELC group were likely to stay one day more in the hospital post-operatively compared to patients had post PTGBD-DLC; MD [95% CI]: 1.09 [0.52, 1.66].
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      • Karakayali F.Y.
      • Akdur A.
      • Kirnap M.
      • Harman A.
      • Ekici Y.
      • Moray G.
      Emergency cholecystectomy vs percutaneous cholecystostomy plus delayed cholecystectomy for patients with acute cholecystitis.
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      However, ELC patients are likely to stay about six days less than post PTGBD-DLC patients in total; MD [ 95% CI]: −6.60 [−10.10, −3.09].
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholecystectomy in acute complicated cholecystitis: comparison of curative efficacy.
      ,
      • Kim I.G.
      • Kim J.S.
      • Jeon J.Y.
      • Jung J.P.
      • Chon S.E.
      • Kim H.J.
      • et al.
      Percutaneous transhepatic gallbladder drainage changes emergency laparoscopic cholecystectomy to an elective operation in patients with acute cholecystitis.
      • Lee R.
      • Ha H.
      • Han Y.S.
      • Kwon H.J.
      • Ryeom H.
      • Chun J.M.
      Percutaneous transhepatic gallbladder drainage followed by elective laparoscopic cholecystectomy for patients with moderate to severe acute cholecystitis.
      • Ni Q.
      • Chen D.
      • Xu R.
      • Shang D.
      The efficacy of percutaneous transhepatic gallbladder drainage on acute cholecystitis in high-risk elderly patients based on the Tokyo guidelines.
      (Fig. 4).
      • -
        Outcomes in complicated AC:
      Figure 4
      Figure 4Length of hospital stay (ELC vs post PTGBD-DLC); a) post-operative hospital stay, b) total hospital stay
      From four studies, operative time was longer in ELC than post PTGBD-DLC but this was not statistically significant; MD [95% CI] 20.9 [−2.19,43.99] min.
      • El-Gendi A.
      • El-Shafei M.
      • Emara D.
      Emergency versus delayed cholecystectomy after percutaneous transhepatic gallbladder drainage in grade II acute cholecystitis patients.
      ,
      • Choi J.W.
      • Park S.H.
      • Choi S.Y.
      • Kim H.S.
      • Kim T.H.
      Comparison of clinical result between early laparoscopic cholecystectomy and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for patients with complicated acute cholecystitis.
      ,
      • Jia B.
      • Liu K.
      • Tan L.
      • Jin Z.
      • Liu Y.
      Percutaneous transhepatic gallbladder drainage combined with laparoscopic cholecystectomy versus emergency laparoscopic cholec